exploring the history of pregnancy, birth, and infant care

Media Literacy and a Short History of the C-Section

Social media is overwhelmed with deliberate misinformation, hearsay, and conspiracy theories. The majority of people sharing misinformation are doing so in ignorance but the people producing the information are usually doing so for monetary gain or power. Today I am going to use a real-life example of the kind of historical misinformation being spread on social media and how you can learn to distinguish between real and fake history posts.

And this isn’t just about the lying liars who create misinformation, it takes two sides for misinformation to spread, the OP and the audience. If we’re going to make social media better for history (or any topic) nerds then both sides have a role to play: for the OP to provide specific sources for claims that are not presented as opinion or fictitious AND for the audience to expect there to be sources, and to verify that the sources provided have supporting evidence for the claims being made and are reputable sources before liking or sharing.

What’s this got to do with c-sections?

This morning I saw a post shared by a couple birth groups that made the claim that African tribes invented c-sections “hundreds of years before Europeans” (as though it’s a competition and if it is, it looks like the Chinese won). The post extrapolated wildly and didn’t cite sources. Of course, this kind of thing happens every day on social media but it was the response of the audience when people asked for sources that concerns me the most.

The information in this screen shot provides a kind of citation, it contains the author name and the content. But it’s also important to include information that will help readers find this post, if still available, such as a link and or a date (Feb. 6th 2019).

When commenters asked for sources the responses from other members of the audience fell under three type:

“Do your own research”

“You’re so rude and so lazy”

“It’s not her job to educate you”

The first and third phrases are your signs to distance yourself from someone asap as they do not have your best intentions in mind; the second one? Well, it might be true but not for asking for sources. When you ask for sources you are attempting to do your own research– research involves verifying information but you cannot verify information if you don’t know where it came from. And if someone is presenting information as facts on a subject they have taken it upon themselves to be educators and it is their responsibility to provide sources, especially if it is an unusual or far-fetched claim, this responsibility is known as the burden of proof.

What’s a source? How is it cited?

Someone even suggested that the following statement in the OP was a source, dummy: “Detailed explanations of Ugandan C-sections were published globally in scholarly journals by the 1880’s and helped the rest of the world learn how to save mothers and babies with minimal complications.”

This is not how a source is cited and, more importantly– it is not true and it’s not an oversight it’s deliberately misleading– but more on that in a moment. A source can be just about anything, a radio program, a podcast, a book, a magazine article, a peer-reviewed article, artwork, a movie, and YouTube video, an advertisement, packaging, a social media post. Some sources will be more reputable than others, but a source doesn’t have to be reputable, you may be citing the source to show how disreputable it was. But the important point is that the source cited is specific so that other people can go find the same exact source and review it for themselves. That’s what makes history fun, imho, different perspectives on the same source makes history that much more colorful. It’s about collaboration and critical inquiry. No one who read the post in question could have found the source the OP used with the information “Ugandan C-sections, published globally, scholarly journals, 1880’s”. If the OP had that much information, they should be able to provide the title of the article(s), the author(s), the name of at least one of the scholarly journals, with date and page numbers, and possibly volume and issue information. When people are trying to push an idea (or lie) it’s common for them make it sound as if it was established in the scientific community, “globally published” means nothing, and when you see language like this, you’re justified in your skepticism.

There are resources available for amateur researchers to help you create citations for your work, such as Citation Machine. Different disciplines (or subjects) have different style guides for citations. As an anthropology undergrad, I was taught to use Chicago; as a grad student in history my professors didn’t really care what I used so long as I was consistent throughout. When I was high school I was told to use MLA (Modern Language Association) formatting; another prevalent style is APA (American Psychological Association). To learn more about style guides I recommend Purdue’s OWL guide.

Finding Sources

The only actual source for any of her claims was the image used in her post. I used a reverse image search to look it up. I found her likely source, an NIH essay, Cesarean Section- A Brief History by Jane Elliot Sewell intended to accompany an exhibit at The National Library of Medicine in 1993 demonstrating that the concept of the c-section has been known all around the “old world” in literature and art for at least two millennia. It did not support the claims of the Facebook post at all, in fact, it contradicted them. So it’s no wonder Juniper wouldn’t want to share the source with her audience.

Sewell’s essay, is a secondary source. Considering that Sewell wrote it for the National Institute of Health and was used by the The National Library of Medicine, we can assume it’s a fairly reputable source. However, as a historian, I always prefer to have a gander at primary sources. Primary sources are first hand or contemporary accounts, or the original source.

Using the information in Sewell’s essay I was able to find R. W. Felkin. He was an anthropologist who had a transcript of a speech he gave at a dinner for obstetricians who had long been performing cesareans. His speech about positions in childbirth he witnessed in Africa on his travels. It was published in one journal, the Edinburgh Medical Journal in April 1884, “Some Notes on Labor in Central Africa”. It was seven pages long in a journal at least 930 pages long and way in the back, it’s on pages 922-930. A presentation of labor positions should have been treated with respect and consideration but was treated as entertainment (and possibly a reason to share crude sketches of naked women) BUT I’m getting ahead of myself, more on the transcript later.

The History of C-Sections

Part one of Jane Sewell’s essay discusses c-sections in antiquity around the world including:

“Ancient Chinese etchings depict the procedure on apparently living women.”

Then we head to Switzerland in the late middle ages:

(Jacob Nufer is dubious AF.)

“Perhaps the first written record we have of a mother and baby surviving a cesarean section comes from Switzerland in 1500 when a sow-gelder [removes pig testicals], Jacob Nufer, performed the operation on his wife […] The mother lived and subsequently gave birth normally to five children, including twins.”

But considering the quality of citation in the late middle ages, this is basically the 16th century equivalent of Juniper Russo’s Facebook post. But it does link the role of animal husbandry to the use of c-sections. Farmers would have been experienced in butchery (animal anatomy) as well as assisting domesticated animals in difficult childbirth. It’s not hard to imagine that in not wanting to lose the mother animal or the calf (for example) an experienced farmer may have performed surgical delivery and attempted to sew up the mother and keep her alive.

Part two of the essay begins with the early 19th century,

Not “masquerading as a man”, Dr. Barry was transgender he lived as a man.

“The first recorded successful cesarean section in the British Empire, however, was conducted by a woman. Sometime between 1815-1821, James Miranda Stuart Barry performed the operation while masquerading as a man and serving as a physician to the British Army in South Africa.”

In the following sixty-odd years, ether, popularized by Queen Victoria, started to be used for pain relief both during labor and for cesarean sections in Britain. At first, it was considered controversial, not because obstetricians thought women should feel pain in childbirth ala original sin, but because they felt that the pain helped women get themselves into better positions for birth and helped attendants know how they were progressing. … but, y’know all the cool kids were doing it.

And here’s where we get to what we were looking for:

“In 1879, for example, one British traveler, R. W. Felkin, witnessed cesarean section performed by Ugandans. The healer used banana wine to semi-intoxicate the woman and to cleanse his hands and her abdomen prior to surgery. He used a midline incision and applied cautery to minimize hemorrhaging. […] The patient recovered well, and Felkin concluded that this technique was well developed and has clearly been used a long time.”

As it turns out, Felkin never concluded that the technique was well developed or that it had been used a long time. Even with reputable sources, it’s important to verify what the primary sources said. It’s not always possible of course, but if you’re going to post something about Ugandans having performed c-sections for hundreds of years, you darn well better find that Felkin fellow’s writings.

Thinking like a Historian

Before I even got to Felkin’s speech transcription, I had more than a few questions about this R. W. Felkin fellow.

Why was he, a tourist, allowed near a laboring woman?

Why did he assume that the people performing the c-section weren’t trained in modern (19th century) surgical techniques?

What constitutes a “long time”? Juniper Russo thinks that “a long time” means hundreds of years, yet a surgeon can be trained in a few years.

Did Felkin stick around for six or more weeks to ensure the woman’s recovery or did he assume that because she survived the active portion of the surgery she was fine?

Did the surgery affect her fertility?

Was this man was trustworthy?

What are his credentials?

What was the reception of his peers to his publication in the medical journal?

Asking these kinds of questions are important, it’s the raison d’etre of historical research. Without source information, I would not be able to know where NIH got their information in order to answer my questions. Fortunately, I was able to go and read the original source material for myself.

Mr. Felkin was an anthropologist and he made it clear in his introduction that he had limited experience in medicine, having only studied it for two years. Yet on his first trip through Africa, he claims to have spared a laboring woman from being cut with “an ugly looking knife” (after examining her without her consent and against the wishes her of her attendants) by using forceps to deliver the baby. He mentions feeling nervous about his performance when “a crowd of natives” came to see “the white man’s medicine”.

And why was he there in the first place? One of his local servants heard about the birth and thought Mr. Felkin would like some entertainment, asking “You want to see a woman cut open?”

I’m not sure who is sicker, the servant for suggesting it or Mr. Felkin for going.

It was the positioning of the laboring woman and her female friend (fig 1, above) when he entered the hut that sparked his curiosity on the positions African women took during labor. So he endeavored on his travels to get access to birthing women in different areas.

Mr. Felkin, you’re a bit of a creep.

“Many a time I have been denied admission during a labour; but I must confess that not infrequently I have gone by stealth and acted ‘peeping Tom,’ but I hope with better motives than his.”

I do admit that I find his descriptions and sketches of laboring women fascinating. And thought I disapprove of his methods I appreciate the record he made. However, he is still a product of his time. For example, one of his many “noble savage” observations:

“The more naked the tribe, the more decent is the behavior of the people; and nowhere have I seen greater indecency than in Uganda, where it is death for an adult to be seen naked in the streets, but when in the huts all the members of the harem are perfectly nude, save perhaps a circle of beads around the waist, and where the most disgusting dances and customs obtain.”

But you haven’t read this far for the detailed descriptions of labor positions of Central African women in the late 19th century (but if you have click here). Rather, you came to “see a woman cut open”… well, folks, this is graphic, and you have been warned.

“So far as I know, Uganda is the only country in Central Africa where abdominal section is practised with the hope of saving both mother and child. The operation is performed by men, and is sometimes successful; at any rate, one case came under my observation in which both survived. The knife used is represented in Fig. 19. It was performed in 1879 at Kahura. The patient was a fine healthy-looking young woman of about twenty years of age. This was her first pregnancy. I was not permitted to examine her, and only entered the hut just as the operation was about to begin. The woman lay upon an inclined bed, the head of which was placed against the side of the hut. She was liberally supplied with banana wine, and was in a state of semi-intoxication. She was perfectly naked. A band of mbugu or bark cloth fastened her thorax to the bed, another band of cloth fastened down her things, and a man held her ankles. Another man, standing on her right side, steadied her abdomen (see fig 17). The operator stood, as I entered the hut, on her left side, holding his knife aloft with his right hand, and muttering an incantation. This being done, he washed his hands and the patient’s abdomen, first with banana wine and then with water.”

Note that the operator washed the belly and knife first with wine, then with water (there was no concept of germ theory, the water would have recontaminated what the wine may have cleaned) so this would seem to be more of a ritual offering in conjunction with the incantation.

“Then, having uttered a shrill cry, which was taken up by a small crowd assembled outside the hut, he proceeded to make a rapid cut in the middle line, commencing a little above the pubes, and ending just below the umbilicus. The whole abdominal wall and part of the uterine wall were severed by this incision, and the liquor amnii escaped; a few bleeding-points in the abdominal wall were touched with a red-hot iron by an assistant. The operator next rapidly finished the incision in the uterine wall; his assistant held the abdominal walls apart with both hands, and as soon as the uterine wall was divided he hooked it up also with two fingers. The child was next rapidly removed, and given to another assistant after the cord had been cut, and then the operator, dropping his knife, seized the contracting uterus with both hands and gave it a squeeze or two. He next put his right-hand in the uterine cavity through the incision, and with two or three fingers dilated the cervix uteri from within outwards. He then cleared the uterus of clots and the placenta, which had by this time had become detached, removing it through the abdominal wound. His assistant endeavored, but not very successfully, to prevent the escape of the intestines through the wound. The red-hot iron was next used to check some further hemorrhage from the abdominal wound, but I noticed that it was very sparingly applied.”

“All this time the chief ‘surgeon’ was keeping up firm pressure on the uterus, which he continued to do till it was firmly contracted. No sutures were put into the uterine wall. The assistant who had held the abdominal walls now slipping his hands to each extremity of the wound, and a porous grass mat was placed over the wound and secured there. The bands which fastened the woman down were cut, and she was gently turned to the edge of the bed, and then over into the arms of assistants, so that the fluid in the abdominal cavity could drain away on to the floor. She was then replaced in her former position, and the mat having been removed, the edges of the wound, i.e., the peritoneum, were brought into close apposition, seven thin iron spikes, well polished, like acupression needles, being used for the purpose, and fastened by string made from bark cloth (see Fig. 18). A paste prepared by chewing two different roots and spitting the pulp into a bowl was then thickly plastered over the wound, a banana leaf warmed over the fire being placed on top of that, and, finally, a firm bandage of mbugu cloth completed the operation.”

Forty-eight hours after the operation the woman had a fever and was not producing milk, a friend had to nurse the baby. Each day her wound dressing was replaced, the pus being sponged up in the process.

“Eleven days after the operation the wound was entirely healed, and the woman seemed quite comfortable. The uterine discharge was healthy. This was all I saw of the case, as I left on the eleventh day. The child had a slight wound on the right shoulder; this was dressed with pulp, and healed in four days.”

That rapid slash with the knife cut too deep, going through the abdominal wall, the uterus, and the baby’s shoulder. All of the surgical techniques described would have been used in animal husbandry, butchery, and treating wounds sustained by accidents, animal attack, or warfare. This isn’t to discount the skills of the people performing the surgical birth but rather to explain how they may have developed them. Clearly, this was something that required a coordinated effort and prior knowledge, for example, having someone who jobs it was to keep the abdomen held together to prevent the bowels spilling out.

This wasn’t a groundbreaking operation for its time in a global context, and Felkin sharing it to a group of obstetricians was likely more edutainment than intended as professional recommendations for the obstetricians. It was more like watching McGyver: “look at what he could do with the tools at hand. Wow. He’s so lucky that worked”. (Kind of like Felkin with those forceps.) If the obstetricians had been paying attention to Felkin’s story beyond it being an edutainment, they would have jumped at the opportunity to figure out what the healing paste was made of so that they could go patent it and the world may have had an antibiotic ointment decades sooner.

The audience for Felkin’s presentation and article were working in totally different environments and cultures from those of central Africa. Just as it would have been in anywhere in the 19th century, what was groundbreaking about the Ugandan c-section was that the woman and baby survived the ordeal, as Felkin noted, the surgery wasn’t generally successful, he just happened to be present for one in which the mother and baby survived at least 11 days.

One of the “can you share sources please” commenters wondered if a tradition of FGM may have played a part in African woman needing cesareans. Based on the note Felkin made about the “surgeon” manually dilating the cervix from inside the incision does make me wonder. In cases of scar tissue preventing dilation of the cervix, it is possible on an intact vagina to reach in and manually dilate a cervix without gutting a poor woman. But if a hand couldn’t pass through an artificially reduced vaginal opening, then the baby wouldn’t either. It’s terrible just to think about, let alone write out, but in modern cases of infibulation (the most severe form of FGM), the women are cut again, effectively an extreme episiotomy, to allow the baby to be born. So it’s unlikely FGM would have, on its own, been a reason for cesarean.

In summary, if someone makes a claim and doesn’t provide sources it may be an oversight but if they (or their supporters) attack you for asking for sources, something is terribly wrong with their information (and likely with them as a person). If you think that African history is important (and it is, very) and that the contributions of Africans to the world should be respected and universally taught, don’t do it a disservice by debasing it in misinformation.

Update

So I was a total PITA and shared this right on the OP because someone needed to stop the intellectual hemorrhaging and I consider this post a form of mbugu cloth, binding the wound. The first critical comment I received was suitably inane,

“i can understand your article, but are you saying something can not be true unless it is recorded? What do you say about the lack of records from certain regions in the world, the destruction of records by other civilizations in those and other regions, and the early plagiarism before it became law in recent history?” – “Karen”

First off, this isn’t about truth, it’s about facts. The OP presented information as a fact which she claimed was from a published source but failed to provide a source because there wasn’t any for the claims she was making. Deliberately lying about history for a viral post to get clicks during Black History Month, with zero respect for the actual history of African woman depicted in the sketch she used.

But the point of all of this is, is that something cannot be VERIFIED unless it is recorded. Human memory is fleeting and dies with us. People get away with spreading misinformation by ensuring their “information” cannot be verified, and by convincing their followers to oppose those who ask for sources. It’s a bit like brainwashing.

The ancient cesarean sections of China have been verified through art history. Due to the of the work of people like Mr. Felkin, Creeper Extraordinaire, who used both art and language to record the various forms that birth took among the people of central Africa we can learn more about African cultures and historical birth customs. Of course there are unrecorded truths in the world but they dissipate like a ring smoke and the truth of that smoke ring cannot be shared with another person or the future unless it was recorded.

The ability to share our experience is the basis of culture and to share it through time is the basis for the study of history. It is horrifying when people try to destroy historical records, whether burning books, or blowing up monuments but then that act becomes part of the historical record itself. The peoples that Mr.Felkin observed did not have written language and because of that the only way for us to learn about that time, those individual women, is through his work. It is so important to teach literacy and critical thinking so that people can record their history and be able to identify misinformation.